03. Medical History (required)
Do you have, or have you had any of the following?
If you have ticked any of the above or if you feel anything else is medically relevant, then please provide
further details in the space below
If you take any medication, please list them all in the space below:
If you have any allergies, please list them all in the space below:
04. Lifestyle History
Please check below to certify that you have understood the above information and that your answers are accurate and up-to-date. Any incorrect information can be dangerous to your health, so please inform your dentist of any changes